Dental Insurance: What You Should Know
An Open Letter from Gordon J. Christensen, DDS, MSD, PhD, Provo, UT
A WORD TO THE WISE:
AN EXPLANATION OF THIRD PARTY PAYMENT FOR DENTAL CARE
In recent years there has been a significant increase in so called "managed
health care" in which insurance groups make contracts with local
companies to provide healthcare for specified fees and with numerous
regulations and stipulations for patients. Your employer may attempt
to provide insurance for you using one of these managed care programs.
The following information will be helpful to you as you attempt to understand
the concept and its advantages and disadvantages.
In our area, there are basically two types of managed care programs:
PPO (Professional Provider Organization)
An insurance company owning the PPO contracts with your employer
to provide dental care to you. The dentists who participate in the
PPO plan to treat you for significantly reduced fees. They are called "preferred
providers." Only a few dentists in the community participate,
usually younger dentists or mature dentists with less active practices.
Dentists with active practices providing modern "standard of
care" updated dentistry cannot usually participate in the PPO's
because of the low fees and inability to provide services at their
usually high quality level. Insurance companies providing PPO's are
in "business" for one purpose--profit. They use dentists
in need to staff their programs. The profit goes to the PPO owner.
In today's world, with the myriad of new innovations in dentistry,
it is not possible for updated practitioners to provide high level
standard of care services on a continuing basis at a fee level provided
by most PPO's. If you elect to join one of these plans, you can expect
only maintenance level care with few innovations provided by practitioners
selected by the PPO owners.
HMO (Health Maintenance Organization)
Perhaps the biggest threat in quality health care in many years of
practice is the currently vogue HMO. An insurance company HMO makes
a contract with your employer to provide overall health or dental
care for you at an unbelievable low fee level. In our area, the fee
levels of most dental HMO's will not even provide the total of two
dental cleanings (scaling and polishing) per year. The dentist receives
a few dollars per patient per month. Whether the patient is treated
or not. Obviously, the dentist would rather not see the patient and
certainly would rather not do any expensive treatment, almost all
of which must be donated to you by the dentists. Generally in HMO's,
the dentist can only survive financially by not treating the patients.
Who profits from HMO's? Certainly not the patient or the dentist.
You guessed it, the HMO owners! As in PPO's, if you elect an HMO,
you have a similar group of preferred providers who participate in
the plan for the same reason, usually observable by discerning patients.
I'm sorry if I have not painted a beautiful picture. Unfortunately, "managed
care" is not an admirable development in American health care.
It is primarily the owners of the insurance companies--not you.
Traditional "fee for service", freedom of practitioner choice,
dental insurance plans provided excellent dental service for Americans
for decades, and they still do so.
Additionally, a newer form of dental insurance called DIRECT REIMBURSEMENT
(DR) can be obtained by your employer, in which you have complete freedom
of choice about practitioners and the quality level and type of service
that you want. We will be pleased to provide information on DR if you
want it for your employer.
I sincerely hope that you love the American way as much as I. This
is a free country. I want to choose my health practitioner based on
my own criteria, and I want the very best preventative care and treatment
I can get. I don't trust profit motivated companies to select my practitioners,
their fees, or their services. We will be privileged to provide the
best quality oral services to you available today, but I'm sorry I can't
provide such care in any PPO or HMO.
Thanks for support.
Gordon J. Christensen
DDS, MSD, PhD, Prosthodontist
Diplomat American Board Of Prosthodontics (PC)
Health Care Accessibility and Quality Assurance Act (Zainyeh
This year, the Rhode Island General Assembly enacted the most comprehensive
health care reform effort in the history of Rhode Island. The bill
was introduced by Representative George Zainyeh (D. Warwick) and by
Wasylyk, Kelley, Giniatt and Sherlock.
This new law requires that the health department enact a process for
certifying health plans and standardize definitions to assist patients
in making informed decisions regarding health care. Among the terms
required to be standardized are: capitation, co-insurance, medical necessity,
out of network, pre-existing condition, and provider network.
Your dental insurance or benefit plans must disclose the following:
- Benefits of the plan.
- Restrictions or limitations on service including exclusion of categories
of service by procedure, provider, or treatment modality.
- Experimental treatment restrictions.
Plans must provide written disclosure of the following:
- Enrollee's right to seek a second opinion.
- The appeals process.
- Enrollee's right to confidentiality.
- Enrollee's right to be free from discrimination.
- Plan's policy to direct enrollees to particular providers.
- Summary of prior authorization or other review requirements.
- Plan limitations such as co-pays, out-of-pocket or out-of-plan services.
- Criteria used to authorize treatment.
- Schedule of reviews and expenses including service ratios and costs.
The Health Department has begun a comprehensive effort to develop
the rules and policies required by this act. Check back to this
updated information, contact the Rhode Island
Dental Association at (401) 825-7700.
Is Your Dental Plan Fair and Effective?
The Rhode Island Dental Association encourages all employers to provide
their employees with a fair and effective dental benefit plan. This
- ensure the delivery of high quality dental care
- provide employees the right to choose their own dentist
- emphasize preventative care to reduce the need for more costly treatment
- encourage employee participation in dental care decision-making
If you would like a free brochure with further information regarding
your dental plan, please feel free to contact
us at (401) 825-7700.